Tavallali Plastic Surgery

https://tavmd.com/2013/05/10/when-to-have-a-face-lift-surgery/

Looking Good After a Facelift

Healing after cosmetic face lift surgery

Face lift surgery is a common cosmetic plastic surgery used to improve facial features and changes due to aging.

I have written about the technical aspects of face lift surgery in the past, including differences between a full face lift and a mini face lift, and face lift surgery under general anesthesia or local anesthesia. Here are some posts:

https://tavmd.com/2013/04/15/face-lift-with-local-anesthesia/

http://tvamd.com/2013/06/30/face-lift-surgery-by-non-plastic-sugeons/

How long before I look good after a face lift?

This is a common question I get asked by cosmetic patients wanting to have a face lift. Obviously, the healing time after a face lift is an important factor in deciding when to have surgery.

The face is difficult to hide when compared to other body areas that can be covered by clothing.

Bruising and swelling of the face after a face lift can be covered by:

makeup
sunglasses
scarves
hairstyles

But the options are limited, and there is nothing better than time to help the plastic surgery patient recover.

Factors that affect healing after face lifts

There are a number of factors that directly affect healing after face lift surgery.

Genetic factors; thinness of facial skin and friability of facial blood vessels
Hematomas; bleeding under the skin of the face after surgery due to medicines or opening of blood vessels after exertion such as a sneeze or cough
Swelling; common after all surgery but worse in some patients than others
Medicines; can cause reactions that adversely affect healing
Medical conditions; infection, heart or liver problems can affect healing

First week after face lift surgery: you can be seen by family

The first few days after any surgery but specially face lift surgery, you will want to stay at home placing ice on your face and keeping your head elevated. You probably just want to be around close friends or your family. You may have significant bruising and swelling- sometimes enough to close your eyes!

Two weeks after face lift surgery: you can see your friends

By two weeks after your face lift surgery you will look good enough to see your friends. You will still be swollen and maybe even a little bruised, but you are putting on makeup and are out and about.

Three weeks after facial plastic surgery: you can visit with acquaintances

At this time, a great deal of the swelling is gone, and most bruising should also have disappeared. You will still feel some of the normal postoperative feelings of swelling and a “woody feeling” on your face. The incisions should be healing well by now, and sutures may have been removed.

Five weeks after face lift surgery: you can see your enemies!

That’s right—those people who are not your friends, the ones who will eat their hearts out at seeing how good you look! At this time you can appear on TV or at public occasions (marriages, parties, etc.) without being considered “operated on.” Don’t let them come too close; the scars may need another few weeks before looking really good—and a year for the final result.

After a cosmetic face lift surgery, be prepared to take the right amount of time to recover. Also remember the rules above: 2-3 and 5 weeks for seeing different types of people!

https://tavmd.com/2013/07/06/facelift-surgery-and-nerve-injury/

Facial Nerve Injury and Lyme Disease

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Facial nerve injury due to Lyme disease

For those of you who read this blog regularly, you will be familiar with my tribulations and fallen face. I thought initially that the acute facial paralysis I developed one morning upon awakening was due to a condition called Bell’s palsy. See below for more information on the facial nerve and its injury.

https://tavmd.com/2013/07/12/facial-nerve-injury-without-facelfit-surgery/

A few days after writing that post, I saw that I had developed a strange oval-shaped rash on my belly. Facial nerve paralysis + rash + living in the northeastern United States = Lyme disease. I am under treatment with antibiotics now.

The facial palsy has improved, though slowly. Here are my photos at a month’s difference. You can compare them with what I looked like in the earlier post above.

: 1 month post paraylsis at rest

The most annoying part of this ordeal has not been the disfigurement; after all, as a cosmetic plastic surgeon, I am hard-wired for dealing with that. Rather, the annoyances have been a tearing up from my right eye, which cannot close properly and is prone to tearing. That is very annoying.

Also, the loss of taste on one half of my tongue is much more of a handicap than I would have thought. I am no glutton, but loss of taste means there is no enjoyment in eating. I have forgone my second helpings and just eat less because it’s no fun; I have lost 13 pounds, though some of that may be due to the Lyme disease.

Lyme disease

Lyme disease is a tick-borne infection common in the northeastern US. The tick is carried around by deer and jumps onto plants and then onto humans who brush against a blade of grass or a plant. The tick bites us and we become infected by a form of bacteria the tick carries, which leads to infection.

Lyme disease shows many varied symptoms and the diagnosis is sometimes difficult.

A tell-tale “bulls eye rash” may or may not be present ( I had just a big red rash)
Fatigue
Runny nose
Muscle and joint pain
Headaches
Acute facial paralysis

These are some of the symptoms of Lyme disease.

A diagnosis is confirmed by drawing a blood test for the body’s reaction to the bacteria; it often comes back equivocal.

Treatment is with a 3-6 week course of antibiotics, typically Doxycyclin. Recently, a new form of “Lyme” has been identified that is caused by a different bacteria that is not sensitive to Doxycyclin. As for my facial palsy, it will hopefully get better by itself in the next few weeks. There is little to do but treat the Lyme disease and wait for the facial nerve to come back. I exercise the muscles daily to keep them from atrophying.

No treatment can lead to debilitating conditions that essentially make the patient bed-ridden.

The rule is: if you suspect you have Lyme, see a doctor and get treated.

https://tavmd.com/2013/04/15/face-lift-with-local-anesthesia/

Face lift and Facial Nerve Surgery

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Face lift and facial nerve; Botox of the entire face

Face lift surgery has few serious complications, but one of them is injury to the underlying facial nerve. The facial nerve is the primary nerve for facial expressions and innervates face muscles. Plastic surgeons must know about face lift and facial nerve surgery .

Here are some articles about facelift surgery.

https://tavmd.com/2012/05/06/the-face-lift-windswept-look/

The facial nerve has a long and convoluted course. It may seem boring to read this anatomy lesson, but you will need to have an idea of the subject so my next blog makes sense—that one is going to be unnerving (could not resist). Your cosmetic plastic surgeon is intimately aware of this anatomy.

First, as our facial nerve comes out of our brains, it gives off a few branches (chroda tympani) and stapedial (ear) and travels by the tragus cartilage in front of the ear to a higher level. Our facial nerve then splits into five main branches just in front of the ear but still under the facial muscles and gives a combination of sensation and movement to our faces. The nerve comes out to a superficial level past the pupil area. If a branch is damaged during facelift or facial surgery, it may take days or months before function returns.

Branches of the facial nerve

: facial nerve

Deep Facial nerve branches

Chorda tympani – taste to front (anterior) 2/3rd of the tongue
Submandibular/sublingual gland
Stapedial branch – to middle ear stapes muscle

Superficial Facial nerve branches

Temporal – helps to elevate the eyebrow
Zygomatic – helps the cheek to elevate

– helps eye closure

– reflex blinking of lids

Buccal – helps the corner of the mouth/cheeks to elevate
Marginal mandibular – depresses lower lip muscles
Cervical – tightens neck muscles

Facelift surgery

During facelift surgery, the skin of the face is elevated above the fat and muscles of the face. The fat and muscles are elevated and held in place with sutures. The skin is then pulled tight. All facelift surgery occurs in a level above the face muscles. The facial nerve runs below the muscles. Injury to the facial nerve during facelift surgery is hence rare if the surgeon stays above the facial muscles. The facial nerve does become more superficial, piercing the facial muscles as it gets closer to the nose. Injury can occur in the central part of the face.

More commonly there is a temporary lack of function of the facial nerve due to the local anesthesia that is placed in the skin of the face for facelift surgery. The anesthesia gives the same results as paralysis of the superficial branches of the facial nerve.

Botox and botulinum toxin and facial nerve

Botox treatments give very similar results in some cases to facial nerve injury or decreased function. The botulinum toxin will actually stop some of these facial nerve branches from working. If the botulinum toxin is put in the wrong areas, Botox can lead to serious side effects that will require therapy. This is why Botox is only recommended for specific areas of the face, such as the area between the eyebrows, the crow’s feet and the forehead.

So much for the anatomy lesson—stray tuned for the next blog, which shows someone with facial nerve paralysis!

https://tavmd.com/2010/10/28/what-is-a-full-face-lift/

When to Have a Face lift Surgery

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Age for face lift surgery

I often see patients who want to have a facelift surgery. As a cosmetic plastic surgeon, facelift surgery is one of the more common procedures I perform. Here are some articles I have written about facelift surgery:

https://tavmd.com/2012/10/05/face-lift-surgery-a-modern-approach/

One of the questions patients often ask me is, “When to have a face lift surgery?”

The answer to that question is a little more difficult than one would think!

Changes in skin needing facelift

There are a number of changes that make the cosmetic plastic surgery patient see changes in their face that they wish to reverse by facelift surgery. The causes are listed below, but what happens to the face to make the patient see a cosmetic plastic surgeon for a facelift?

Brow skin falls, with eyebrow falling under the upper part of the eye socket
Eyelid skin droops and fat herniates around the eyelids
Cheek skin and fat fall forward, accentuating the lines between the nose and mouth and causing nasolabial lines
Jowl skin and fat droop, causing a squaring of the face and marionette lines
Neck skin becomes loose and the platysma muscles separate and fall down
Skin color changes on the whole face
Facial pores become larger
Fine wrinkles increase in number and skin becomes rough

Timing of facial aging

How our faces age and needing a facelift depends on a number of factors, some within our control and others outside.

Genetics for facelifts

One of the most important factors for determining when to have a facelift surgery is basic genetics. Look at photographs of your mother and father and see when they lost their youthful appearance. You will see that aging occurs in stages. The skin in our faces is like an elastic band that is stretched over the years. Every decade or so, the “elastic band” breaks and we look like we have aged. How often that happens is dictated in part by genetics and hence by how our parents aged.

If by age 45 your mother looked older for her age, it’s a probability that you will, too.

Environment and facelifts

The insults you have heaped upon your skin also affect your facial aging. Sun exposure will actually destroy elastin proteins in your skin, making it sag. This also leads to abnormal skin cell maturation, which gives us skin cancers and “old”-looking skin. Wind exposure will dry out the skin, and the resulting dehydration leads to a wrinkled look. Hence the term “a weather-beaten face”! Protecting your skin is an important part of delaying the need for a facelift.

Facial skin protection to delay facelift

How you care for your skin will obviously affect the quality of your skin and delay the timing of a facelift. Creams that moisturize your skin, sunblocks that prevent the effects of the sun and creams that help the natural repair mechanisms of the skin can all help improve facial skin quality and delay facelifts.

What age to have a facelift at?

If you have taken the above into consideration, you will see that there is no defined age at which to have a facelift. Everyone is different. The youngest patient I have operated on for a facelift was 38 years old, and the oldest was 80! Still, the majority of the skin changes and drooping of the face skin that requires a facelift seems to occur between the ages of 45 and 60. This is when the greatest changes in our faces seem to occur. When should you have a facelift surgery? When you look in the mirror and are bothered by what you see!

Bruising and Bleeding After Plastic Surgery

Bruising after plastic surgery is normal

All surgery will result in blood vessels in the skin being cut and a small amount of bleeding. Of course, deeper structures may also have to be cut, and they will also produce their own bleeding. The bleeding typically stops or is stopped at the time of surgery. Bruising is due to the blood left over.

Blood that is outside of the blood vessels will start to undergo a process of coagulation, where the liquid blood transforms into a clot, which is a jelly-like accumulation.

Under the skin the clot remains in this “jelly-like” form for up to 10 days while it slowly transforms back into:

a yellow-colored liquid (serum) that is absorbed by the body
rust-colored remnants of blood cells—the bruise; this is caused by the iron in the blood, which changes color to red, blue and yellow as it oxidizes and is removed by our white blood cells from the skin; in rare cases, the iron deposits stay in the skin for six months to a year

Normal bleeding under the skin is usually not apparent for a few days unless the skin is very thin, like it is around the eyes. The bruise typically develops over 2-3 days and rises up to the surface of the skin before disappearing.

One of the main jobs of a cosmetic plastic surgeon is to minimize bleeding by tying off blood vessels with sutures or cauterizing blood vessels with electricity. Despite these efforts, a basic principle of surgery, abnormal bleeding can and does occur; this is called a hematoma.

Hematoma, abnormal bleeding, after plastic surgery

Hematoma occurs when there is a large amount of bleeding under the skin or in the body after surgery or due to some other trauma. Hematomas can also occur within body cavities like the abdomen, lungs, muscles, brain, etc. The bleeding typically continues after the surgery and does not stop. If the hematoma is under the skin it initially looks like a large bruise and can be easily diagnosed. If the hematoma occurs deeper in the body, such as under the chest muscle after a breast augmentation, it may be difficult to diagnose without a CT scan.

In cases of hematoma, the normal process of removing blood that occurs with normal bleeding and bruising is overwhelmed. There is just too much blood for the body to handle, and the larger amount of bleeding causes:

stretching of skin and pain
decreased blood supply to skin with possibility of skin dying
sometimes even more bleeding due to biochemical processes that start up!

This can lead to death!

When a large hematoma occurs, it usually cannot be left alone to be reabsorbed by the body and requires a second surgery to remove blood and stop the source of bleeding if it is continuing.

In summary:

Signs of bruising or hematoma

less blood loss or more blood loss
color changes on skin; color changes may not be visible on skin
smaller amount of swelling or greater amount of swelling
less pain or more pain
self-limiting; may need surgical evacuation

https://tavmd.com/2012/11/13/how-to-decrease-swelling-after-cosmetic-plastic-surgery/

Lymphatic Drainage after Cosmetic Surgery

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Swelling after surgery

All cosmetic plastic surgeries will produce swelling as a normal healing reaction. Some cosmetic surgeries, such as tummy tucks and liposuction, will disrupt the natural body conduits more by the sheer area that undergoes surgery. Other body areas, such as the nose, have different types of swelling that persist for up to a year, such as after a rhinoplasty. Some procedures, such as face lifts, will have swelling persist for up to six months. I have discussed in the past some of the ways to reduce swelling after surgery:

Today I want to specifically discuss the use of lymphatic drainage massage as a way to reduce swelling after cosmetic surgery such as liposuction and abdominoplasty.

What is lymph and what are lymphatics?

Most people know that our bodies have a series of vessels that carry blood from the heart to tissues (arteries and arterioles) and others that carry blood back from tissues to the heart (veins and venules). What most people do not know is that there is a whole other system of vessels running parallel to arteries and veins that transport lymph throughout the body. These are lymphatics, and they carry around lymph! You have all seen lymph when you have burnt yourself and your skin has formed a blister. Lymph is essentially blister fluid!

Lymph is a yellow liquid that can be thought of as the fluid in which blood cells travel. The combination of blood cells and lymph (plasma) is blood. When blood arrives at our tissues, oxygen is released from red blood cells and dissolved in lymph, which, because of pressure differentials between arteries and veins, is distributed into tissues. While most of this fluid goes back into the blood vessels, a small portion, about three liters a day, stays around the tissues and is then collected in lymphatic vessels and taken back to be re-introduced into the bloodstream in three main areas after going through a series of collection areas called lymph nodes. Each side of the body, thigh and leg empties into the femoral vein on each side of the groin, and the lymphatics of the head and neck drain into the subclavian vein on the left side of the neck.

Injury and lymphatics

When a part of the body is injured, there is an increase in the permeability of blood vessels in that area, and more lymph spills out into tissues. We see this as swelling. The more “injury” to an area, such as after a tummy tuck with liposuction, the more swelling and lymph in tissues. In some surgeries, such as abdominoplasty, where skin is elevated from underlying abdominal muscles, lymphatics must be cut and must re-establish continuity and grow together before they can remove the fluid from the area. If this does not happen fast enough and lymph hangs around, you have what is known as a seroma.

When there is an injury or infection, the increased amount of lymph and increase in white blood cells that get recruited to the area of injury will lead to enlargement of the lymph nodes. This is why you feel lymph nodes when you have a cold!

In surgeries where lymph nodes are removed for disease, as occurs after breast cancer mastectomy, injury to lymph nodes and lymphatics can lead to accumulation of fluid within the limb or area of injury, a condition known as lymphedema (swelling due to lymph).

While providing a series of channels for white blood cells and body defenses to get to areas of injury or trauma, the lymphatics also provide for a way for infection to spread through the body. Red streaks up an arm after an injury to a finger are a sign of infection in the lymphatics!

Lymphatic drainage

Most swelling a cosmetic plastic surgeon sees after surgery such as tummy tucks or liposuction is expected. There are a number of techniques to decrease swelling, such as garments, elevation of the affected body part and icing of the area to decrease the amount of blood coming and hence the amount of swelling. Once swelling is present, though, massage can help greatly. Lymphatic drainage is a type of massage to help empty lymphatics in the area of surgery that has retained lymph. It is a very superficial massage and is more like a firm stroke rather than a deep tissue muscle massage. Lymph is pushed through the lymphatics, and swelling decreases.

Lymphatic drainage is a useful and beneficial ancillary procedure to cosmetic surgery procedures such as tummy tucks and liposuction where there are large areas of damage to lymphatics. For smaller areas of cosmetic surgery, such as the nose after rhinoplasty or face after a facelift, patients can massage themselves, but for larger areas, help from a massage therapist trained in lymphatic drainage is well worth any cost.